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Removal of the magnetic sphincter augmentation device: an assessment of etiology, clinical presentation, and management. Surg Endosc 2023; 37:3769-3779. [PMID: 36689039 PMCID: PMC10156860 DOI: 10.1007/s00464-023-09878-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 01/08/2023] [Indexed: 01/24/2023]
Abstract
BACKGROUND Magnetic sphincter augmentation (MSA) erosion, disruption or displacement clearly requires device removal. However, up to 5.5% of patients without anatomical failure require removal for dysphagia or recurrent GERD symptoms. Studies characterizing these patients or their management are limited. We aimed to characterize these patients, compare their outcomes, and determine the necessity for further reflux surgery. METHODS This is a retrospective review of 777 patients who underwent MSA at our institution between 2013 and 2021. Patients who underwent device removal for persistent dysphagia or recurrent GERD symptoms were included. Demographic, clinical, objective testing, and quality of life data obtained preoperatively, after implantation and following removal were compared between removal for dysphagia and GERD groups. Sub-analyses were performed comparing outcomes with and without an anti-reflux surgery (ARS) at the time of removal. RESULTS A total of 40 (5.1%) patients underwent device removal, 31 (77.5%) for dysphagia and 9 (22.5%) for GERD. After implantation, dysphagia patients had less heartburn (12.9-vs-77.7%, p = 0.0005) less regurgitation (16.1-vs-55.5%, p = 0.0286), and more pH-normalization (91.7-vs-33.3%, p = 0.0158). Removal without ARS was performed in 5 (55.6%) GERD and 22 (71.0%) dysphagia patients. Removal for dysphagia patients had more complete symptom resolution (63.6-vs-0.0%, p = 0.0159), freedom from PPIs (81.8-vs-0.0%, p = 0.0016) and pH-normalization (77.8-vs-0.0%, p = 0.0455). Patients who underwent removal for dysphagia had comparable symptom resolution (p = 0.6770, freedom from PPI (p = 0.3841) and pH-normalization (p = 0.2534) with or without ARS. Those who refused ARS with removal for GERD had more heartburn (100.0%-vs-25.0%, p = 0.0476), regurgitation (80.0%-vs-0.0%, p = 0.0476) and PPI use (75.0%-vs-0.0%, p = 0.0476). CONCLUSIONS MSA removal outcomes are dependent on the indication for removal. Removal for dysphagia yields excellent outcomes regardless of anti-reflux surgery. Patients with persistent GERD had worse outcomes on all measures without ARS. We propose a tailored approach to MSA removal-based indication for removal.
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Athanasiadis DI, Selzer D, Stefanidis D, Choi JN, Banerjee A. Postoperative Dysphagia Following Esophagogastric Fundoplication: Does the Timing to First Dilation Matter? J Gastrointest Surg 2021; 25:2750-2756. [PMID: 33532983 DOI: 10.1007/s11605-021-04930-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 01/15/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Postoperative dysphagia after anti-reflux surgery typically resolves in a few weeks. However, even after the initial swelling has resolved at 6 weeks, dysphagia can persist in 30% of patients necessitating esophageal dilation. The purpose of this study was to investigate the effect of esophageal dilation on postoperative dysphagia, the recurrence of reflux symptoms, and the efficacy of pneumatic dilations on postoperative dysphagia. METHODS A prospectively collected database was reviewed for patients who underwent partial/complete fundoplication with/without paraesophageal hernia repair between 2006 and 2014. Patient age, sex, BMI, DeMeester score, procedure type, procedure duration, length of stay, postoperative dysphagia, time to first pneumatic dilation, number of dilations, and the need for reoperations were collected. RESULTS The study included 902 consecutive patients, 71.3% females, with a mean age of 57.8 ± 14.7 years. Postoperative dysphagia was noted in 26.3% of patients, of whom 89% had complete fundoplication (p < 0.01). Endoscopic dilation was performed in 93 patients (10.3%) with 59 (63.4%) demonstrating persistent dysphagia. Recurrent reflux symptoms occurred in 35 (37.6%) patients who underwent endoscopic dilation. Patients who underwent a dilation for symptoms of dysphagia were less likely to require a revisional surgery later than patients who had dysphagia but did not undergo a dilation before revisional surgery (17.2% vs 41.7%, respectively, p < 0.001) in the 4-year follow-up period. The duration of initial dilation from surgery was inversely related to the need for revisional surgery (p = 0.047), while more than one dilation was not associated with additive benefit. CONCLUSION One attempt at endoscopic dilation of the esophagogastric fundoplication may provide relief in patients with postoperative dysphagia and can be used as a predictive factor for the need of revision. However, there is an increased risk for recurrent reflux symptoms and revisional surgery may ultimately be indicated for control of symptoms.
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Affiliation(s)
| | - Don Selzer
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Dimitrios Stefanidis
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jennifer N Choi
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Ambar Banerjee
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.
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Bjelović M, Harsányi L, Altorjay Á, Kincses Z, Forsell P. Non-active implantable device treating acid reflux with a new dynamic treatment approach: 1-year results : RefluxStop™ device; a new method in acid reflux surgery obtaining CE mark. BMC Surg 2020; 20:159. [PMID: 32689979 PMCID: PMC7370422 DOI: 10.1186/s12893-020-00794-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 06/09/2020] [Indexed: 01/29/2023] Open
Abstract
Background RefluxStop™ is an implantable, non-active, single use device used in the laparoscopic treatment of GERD. RefluxStop™ aims to block the movement of the LES up into the thorax and keep the angle of His in its original, anatomically correct position. This new device restores normal anatomy, leaving the food passageway unaffected. Methods In a prospective, single arm, multicentric clinical investigation analyzing safety and effectiveness of the RefluxStop™ device to treat GERD, 50 subjects with chronic GERD were operated using a standardized surgical technique between December 2016 and September 2017. They were followed up for 1 year (CE-mark investigation 6-months). Primary safety outcome was prevalence of serious adverse events related to the device, and primary effectiveness outcome reduction of GERD symptoms based on GERD-HRQL score. Secondary outcomes were prevalence of adverse events other than serious adverse events, reduction of total acid exposure time in 24-h pH monitoring, and reduction in average daily PPI usage and subject satisfaction. Results There were no serious adverse events related to the device. Average GERD-HRQL total score at 1 year improved 86% from baseline (p < 0.001). 24-h pH monitoring compared to baseline showed a mean reduction percentage of overall time with pH < 4 from 16.35 to 0.80% at the 6-month visit (p < 0.001), with 98% of subjects showing normal 24-h pH. At 1 year: No new cases of dysphagia were recorded, present in 2 subjects, which existed already at baseline. Regular daily PPI usage occurred in all 50 subjects at baseline. At 1-year follow-up, only 1 subject took regular daily PPIs due to a too low placement of the device thereby prohibiting its function. None or minimal occasional episodes of regurgitation occurred in 97.8% of evaluable subjects. Gas bloating disappeared in 30 subjects and improved in 7 subjects. Conclusion The new principle of RefluxStop™ is safe and effective to treat GERD according to investigation results. At 1-year follow-up, both the GERD-HRQL score and 24-h pH monitoring results indicate success for the new treatment principle. In addition, with the dynamic treatment for acid reflux, which avoids compressing the food passageway, prevalence of dysphagia and gas bloating are significantly reduced. Trial registration ClinicalTrials.gov, NCT02759094. Registered 3 May, 2016,
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Affiliation(s)
- Miloš Bjelović
- Department for Minimally Invasive Upper Digestive Surgery, University Hospital for Digestive Surgery - First Surgical Hospital, Clinical Center of Serbia; University of Belgrade, School of Medicine, Belgrade, Serbia.
| | - László Harsányi
- 1st Department of Surgery, Semmelweis University, Budapest, Hungary
| | - Áron Altorjay
- Surgical Department, Fejér County Szent György University Teaching Hospital, Székesfehérvár, Hungary
| | - Zsolt Kincses
- General Surgery Department, University of Debrecen Kenézy Gyula Teaching Hospital, Debrecen, Hungary
| | - Peter Forsell
- Inventor of RefluxStop™, Seehof 4b, 6072, Sachseln, Switzerland
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Preoperative High-Resolution Manometry Criteria are Associated with Dysphagia After Nissen Fundoplication. World J Surg 2018; 43:1062-1067. [PMID: 30523393 DOI: 10.1007/s00268-018-4870-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Dysphagia after Nissen fundoplication is challenging for patients. High-resolution manometry (HRM) has rarely been studied preoperatively to determine whether manometry values correlated with postoperative dysphagia after fundoplication. We aim to determine whether HRM criteria could predict dysphagia after Nissen fundoplication. METHODS A retrospective review of single-institution laparoscopic Nissen fundoplications (LNF) from 2013 to 2015 was completed. Dysphagia was graded using a standard scale. Four groups were: those with new postoperative dysphagia (ND), never had dysphagia (NV), continued dysphagia (CD), and resolved dysphagia (RD). Manometry criteria included distal contractile integral (DCI), contraction front velocity (CFV), distal latency (DL), integrated relaxation pressure (IRP), percent peristalsis (PP), and distal esophageal contraction amplitude (DECA). Statistical bootstrapping was used to power sample sizes for ANOVA analysis. RESULTS Ninety-four patients were included in the original cohort. Statistical bootstrapping sample size was 2992 patients. Among patients who did not have dysphagia prior to LNF, no HRM metric was associated with developing new dysphagia. Among those with dysphagia prior to LNF, a higher DCI, CFV, DL, PP, and DECA were associated with resolution of dysphagia. The RD group was 2.77 times more likely to have a DCI ≥ 1000 mmHg-s-cm compared with the CD group. CONCLUSIONS HRM criteria could not predict the development of postoperative dysphagia. However, in those with preoperative dysphagia and strong manometry criteria, dysphagia is more likely to resolve after Nissen fundoplication. Meanwhile, in those with preoperative dysphagia and weak manometry, dysphagia may persist and these patients may be better served with a partial fundoplication.
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Atie M, Khoma O, Dunn G, Falk GL. Gastrointestinal tract obstruction secondary to post-operative oedema: does dexamethasone administration help? J Surg Case Rep 2016; 2016:rjw139. [PMID: 27554826 PMCID: PMC4994521 DOI: 10.1093/jscr/rjw139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Oedema can occur in handled tissues following upper gastrointestinal surgery with anastomosis formation. Obstruction of the lumen may result in delayed return of enteric function. Intravenous steroid use may be beneficial. Three cases of delayed emptying following fundoplication, gastro-enteric and entero-enteric anastomoses are reviewed. Conservative management with supportive measures failed. Dexamethasone was administered to treat the oedematous obstruction. A literature review in PubMed, Cochrane database and Medline for English language publications on the use of dexamethasone in the treatment of acute post surgical oedema of the upper gastrointestinal was conducted. Administration of dexamethasone led to resolution of symptoms and successful outcome. No reports on the use of steroids in this context were identified in the literature. The use of dexamethasone may effectively treat intestinal obstruction due to inflammatory or oedematous cause in the early post-operative period.
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Affiliation(s)
- M Atie
- Department of Upper GI Surgery, Concord Repatriation General Hospital, Sydney, Australia
| | - O Khoma
- Department of Upper GI Surgery, Concord Repatriation General Hospital, Sydney, Australia
| | - G Dunn
- Department of Radiology, Concord Repatriation General Hospital, Sydney, Australia
| | - G L Falk
- Department of Upper GI Surgery, Concord Repatriation General Hospital, Sydney, Australia
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Ozcan CU, Yilmaz O, Gurer DE, Ayhan S, Taneli C, Genc A. Evaluation of the relation between interstitial cells of cajal (CD117) and serotonin receptor (5HT-3A) with postfundoplication dysphagia. Int J Surg 2014; 13:137-141. [PMID: 25498492 DOI: 10.1016/j.ijsu.2014.11.053] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Revised: 11/17/2014] [Accepted: 11/25/2014] [Indexed: 01/29/2023]
Abstract
OBJECTIVE The aim of the present study is to investigate the effect of Nissen fundoplication to the pacemaker cells of an intestinal system and the serotonin receptors on an ICC membrane. METHODS Sixteen adult male rats were taken into study. Rats were divided in to the following two groups. Nissen fundoplication was performed to study group (Group 1) and no surgical procedures were applied to control group (group 2). The rats who were subjected to surgery and the rats without surgery were sacrificed on to postoperative 14 days. Specimens for the pathologic analysis were obtained from upper esophagus (group A) and esophagogastric junction (EGJ) (group B). Distribution of ICC and 5HT-3A were evaluated separately. RESULTS There was a significant difference (p=0.01, p=0.02, respectively) regarding number of cells stained with CD117 between the group 1B-2B and group 2A-2B. Also there was a significant difference between (p=0.01, p=0.01 respectively) number of cells stained with 5HT-3A in groups 1A-1B and 2A-2B. However, no correlation was detected between group 1B-2B for 5HT-3A. CONCLUSION A reduction in the number of ICC was observed in esophagogastric junctions of the fundoplication group but 5HT-3A distribution did not show a significant difference. A decrease in the number of ICC may be effective at postfundoplication dysphagia.
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Affiliation(s)
- Cansu Unden Ozcan
- Balikesir University, Med. Faculty, Dept. of Pediatric Surgery, Balikesir, Turkey
| | - Omer Yilmaz
- Celal Bayar University, Med. Faculty, Dept. of Pediatric Surgery, Manisa, Turkey.
| | - Deniz Ersayin Gurer
- Celal Bayar University, Med. Faculty, Dept. of Pediatric Surgery, Manisa, Turkey
| | - Semin Ayhan
- Celal Bayar University, Med. Faculty, Dept. of Pathology, Manisa, Turkey
| | - Can Taneli
- Celal Bayar University, Med. Faculty, Dept. of Pediatric Surgery, Manisa, Turkey
| | - Abdulkadir Genc
- Celal Bayar University, Med. Faculty, Dept. of Pediatric Surgery, Manisa, Turkey
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Fuchs HF, Gutschow CA, Brinkmann S, Herbold T, Bludau M, Schröder W, Bollschweiler E, Hölscher AH, Leers JM. Effect of laparoscopic antireflux surgery on esophageal motility. Dig Surg 2014; 31:354-8. [PMID: 25503359 DOI: 10.1159/000368662] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Accepted: 09/22/2014] [Indexed: 01/12/2023]
Abstract
BACKGROUND/AIMS The effect of laparoscopic antireflux surgery on esophageal motility is incompletely understood, and any indication for this procedure in patients with motility disorder is disputed in literature. We evaluated the influence of laparoscopic Nissen fundoplication on impaired esophageal motility. METHODS In this pathological manometric study, we divided the patients into two groups preoperatively: the hypomotility group (mean amplitude of esophageal contraction wave <40 mm Hg; HYPO group, n = 11) and the normal group (mean amplitude of esophageal contraction wave >40 mm Hg; NORM group, n = 43). The amplitudes of esophageal contraction waves 3 and 8 cm above the lower esophageal sphincter and the percentage of peristaltic contraction waves of the tubular esophagus were analyzed pre- and postoperatively. RESULTS In total, 54 patients with GERD underwent esophageal manometry before and 6 months after Nissen fundoplication. The length and pressure of the lower esophageal sphincter were increased in both groups postoperatively (p < 0.01). Patients in the HYPO group (n = 11) showed a statistically significant increase of mean amplitude of esophageal contraction (32.8 vs. 57.3 mm Hg; p < 0.01), while no change was found in the NORM group (n = 43). A total of 72% of patients with preoperative motility disorder showed normal postoperative manometry. CONCLUSION Nissen fundoplication normalizes esophageal motility, especially in patients with preoperative hypomotility. Patients with impaired esophageal motility should not per se be excluded from antireflux surgery.
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Affiliation(s)
- Hans F Fuchs
- Department of General, Visceral and Cancer Surgery, University of Cologne, Cologne, Germany
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Lundell L, Bell M, Ruth M. Systematic review: Laparoscopic fundoplication for gastroesophageal reflux disease in partial responders to proton pump inhibitors. World J Gastroenterol 2014; 20:804-813. [PMID: 24574753 PMCID: PMC3921489 DOI: 10.3748/wjg.v20.i3.804] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Revised: 09/20/2013] [Accepted: 11/13/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To assess laparoscopic fundoplication (LF) in partial responders to proton pump inhibitors (PPIs) for gastroesophageal reflux disease (GERD).
METHODS: We systematically searched PubMed and Embase (1966-Dec 2011) for articles reporting data on LF efficacy in partial responders. Due to a lack of randomized controlled trials, observational studies were included. Of 558 articles screened, 17 were eligible for inclusion. Prevalence data for individual symptoms were collated across studies according to mutually compatible time points (before and/or after LF). Where suitable, prevalence data were presented as percentage of patients reporting symptoms of any frequency or severity.
RESULTS: Due to a lack of standardized reporting of symptoms, the proportion of patients experiencing symptoms was recorded across studies where possible. After LF, the proportion of partial responders with heartburn was reduced from 93.1% (5 studies) to 3.8% (5 studies), with similar results observed for regurgitation [from 78.4% (4 studies) to 1.9% (4 studies)]. However, 10 years after LF, 35.8% (2 studies) of partial responders reported heartburn and 29.1% (1 study) reported regurgitation. The proportion using acid-suppressive medication also increased, from 8.8% (4 studies) in the year after LF to 18.2% (2 studies) at 10 years. In the only study comparing partial responders to PPI therapy with complete responders, higher symptom scores and more frequent acid-suppressive medication use were seen in partial responders after LF.
CONCLUSION: GERD symptoms improve after LF, but subsequently recur, and acid-suppressive medication use increases. LF may be less effective in partial responders than in complete responders.
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Perretta S, McAnena O, Botha A, Nathanson L, Swanstrom L, Soper NJ, Inoue H, Ponsky J, Jobe B, Marescaux J, Dallemagne B. Acta from the EndoFLIP® Symposium. Surg Innov 2013; 20:545-52. [PMID: 24379172 DOI: 10.1177/1553350613513515] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Laparoscopic fundoplication (LF) is a surgical treatment for gastroesophageal reflux disease (GERD) that has been performed for more than 20 years. High-volume centers of excellence report long-term success rates greater than 90% with LF. On the other hand, general population-based outcomes are reported to be markedly worse, leading to a nihilistic perception of the procedure on the part of the medical referral population. The lack of standardization of the technique and the lack of tools to calibrate objectively the repairs are probably among the causes of variability in the outcomes and may explain the decline in the number of LF procedures in recent years. The functional lumen imaging probe (EndoFLIP(®)) device is essentially a "smart bougie" in the form of a balloon catheter that measures shape and compliance of the gastroesophageal junction (GEJ) during surgery using impedance planimetry. With approximately 3 years of international experience gained with this tool, a symposium was convened in October 2012 in Strasbourg, France, with the aim of determining if intraoperative EndoFLIP use could provide standardization of surgical treatment of GERD through the understanding of physiological changes occurring to the GEJ during fundoplication. This article provides a brief history of the EndoFLIP system and reviews data previously published on the use of EndoFLIP to characterize the GEJ in normal subjects. It then summarizes the data from the 5 high-volume international sites with expert surgeons performing LF presented in Strasbourg to objectively profile the characteristics of a normal postoperative GEJ.
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Affiliation(s)
- Silvana Perretta
- 1IRCAD, Department of Digestive and Endocrine Surgery, University of Strasbourg, Strasbourg, France
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Allaix ME, Herbella FA, Patti MG. Laparoscopic total fundoplication for gastroesophageal reflux disease. How I do it. J Gastrointest Surg 2013; 17:822-8. [PMID: 23129120 DOI: 10.1007/s11605-012-2068-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2012] [Accepted: 10/15/2012] [Indexed: 01/31/2023]
Abstract
INTRODUCTION A laparoscopic fundoplication is considered today the procedure of choice for the treatment of gastroesophageal reflux disease (GERD). DISCUSSION Several eponyms are used in the literature to denote different antireflux operations: Nissen, Nissen-Rossetti, Toupet, Lind, Guarner, Hill, and Dor. We feel that it is more important to focus on the technical elements which make a fundoplication effective and long lasting. The type of fundoplication (total vs. partial) is tailored to the quality of esophageal peristalsis as documented by the preoperative manometry. In the USA, a partial fundoplication is chosen only for patients with very impaired or absent esophageal peristalsis. CONCLUSION This article describes the technique of laparoscopic total fundoplication for GERD. Partial fundoplication is performed following the same technical elements as the total fundoplication. A 240° to 270° wrap rather than a 360° wrap is performed.
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Affiliation(s)
- Marco E Allaix
- Department of Surgery and Center for Esophageal Diseases, University of Chicago Pritzker School of Medicine, 5841 S. Maryland Ave, MC 5095, Room G-207, Chicago, IL 60637, USA
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